I dont know the drill
October 21, 2010 8:01 PM   Subscribe

My dentist put a temp crown on a broken tooth today, then sent me to the front desk to set a followup. I was expecting this to be covered, at least partly, by my insurance, but they told me I had reached the limit and asked for $600. Is this right? Should they have told me I'd be paying out of pocket before starting treatment?

I have received a lot of good and necessary work from this office, but I feel pretty shafted right now. They took great care of me when I had a bad infection earlier in the year, and a couple of other fillings, but at the same time they were paid handsomely for the treatment by my insurance (yearly limit of $1500).

I can cover the $600 but its far from water off a ducks back for me and I certainly would have waited two more months to have this done in '11 had I known about the limit (to broke over a year ago, still had no pain).

Should I finish treatment and then bring up the issue? Should I expect a discount? I've paid for half the cost already, which I'd be fine leaving for a retainer until insurance reimbursement. Could I ask him to bill me it '11? Any other creative options on how to deal with this?
posted by anonop to Human Relations (20 answers total)
 
It's your responsibility to know how much money you have left in your yearly coverage. You said yourself that you'd had a bad infection and a couple of other fillings (plus cleanings, I would imagine) and that your limit is $1500.
posted by kate blank at 8:08 PM on October 21, 2010 [6 favorites]


It's not the dentist's responsibility to know your coverage limits. That's all you.

Can you ask the dentist to let you pay for the temp crown in installments? Do you have a FSA at work? Maybe you could use those funds to cover all or part. Not sure why you would deserve a discount, but it never hurts to ask for a break. If it would have been covered 80/20, for example, ask if he would accept 80% as payment in full.

Ask the doctor to wait on the remainder of the work that needs to be done until your new coverage year starts. Asking him to bill this year's work in another year is asking him to commit fraud.
posted by contessa at 8:09 PM on October 21, 2010


Take a look at your dental insurance agreement. You're responsible for tracking it, not your dentist. Most dental plans give you a certain amount of coverage for regular visits, and a different amount of coverage for this kind of procedure, and then have an annual benefit maximum. Sounds like you've exceeded the maximum. In any case, it should all be spelled out in your insurance, and if you have questions it's your insurance provider (or start with HR if it's through employment) that will have the answers. All the dentists do is bill the insurance company in accordance with your contract, until they can't any more.

You won't be able to get a bill in '11, because your insurance plan year usually won't cover payments for work done in the previous year.

I feel for you; it's not a fun procedure and it's too bad it didn't wait until 2011. But it sounds like you have things turned around: it's not your dentist that is going to have the best information about where you are in terms of your use of your plan benefits over the course of the year. THat's yours to track. If you have questions about how they are allowed to bill something, and whether there are any things you can do to make billing easier on your cash flow, sometimes the dentists' office can be a great help; but basically, the responsibility for payment falls between you and your plan adminstrators and insurance company. It sounds like you weren't that familiar with the terms of your agreement, so you should definitely sit down now and review the documents to see what they will and won't cover in a given year. It really helps to know that stuff, so you can plan your dental work accordingly, to the degree possible.
posted by Miko at 8:10 PM on October 21, 2010


Should they have told me I'd be paying out of pocket before starting treatment?
Not their responsibility.

Should I finish treatment and then bring up the issue?
Bring it up now. They may have an idea for making it easier on you.

I feel pretty shafted right now. They took great care of me when I had a bad infection earlier in the year, and a couple of other fillings, but at the same time they were paid handsomely for the treatment by my insurance (yearly limit of $1500).
Yes, they were paid. For work that they did. That has no bearing on the current situation. From their perspective, "He paid us, but at the same time, we did a great job." It all evens out.

It's not their fault you lost track of your insurance coverage, sorry. If they're willing to work with you, terrific, but don't be the one to suggest that they commit insurance fraud. They have way more to lose than you do, and they may get very offended and refuse to have anything further to do with you for just that reason.
posted by Etrigan at 8:11 PM on October 21, 2010


Oh yeah - most dentists will work out a payment plan of installments with you if you tell them it's a hardship to pay at once. Try that to ease this surprise.
posted by Miko at 8:11 PM on October 21, 2010


So yes you should get an estimate up front. Yes you should ask to be told when you've reached your limit. Yes this is also your fault for not knowing your limits and how close you were to them. No it is not your dentists job to recommend you wait until next year for work. Yes some dentist offices will warn you about this. No you should not expect a discount.
posted by bitdamaged at 8:12 PM on October 21, 2010


you could ask for a payment plan, sure. but you do owe them that money if your limit was up. you, as a consumer, unfortunately, have the responsibility to cover your own ass. the dentist's office could have told you as a courtesy, but it is not ultimately their job. if an office does that for you, great. otherwise, there are no laws governing this kind of issue. i am speaking from experience. i recently researched something close to this issue. you are 100% in the right to complain to the office and guilt them into either a discount or a payment plan, but ultimately, the responsibility is on you, the consumer, as the dude with the insurance plan.
posted by lakersfan1222 at 8:13 PM on October 21, 2010


ditto...your responsibility, not the girl in the office....
posted by HuronBob at 8:17 PM on October 21, 2010


Oh and to put it more simply at the end of the day this is your fault. Don't deflect on your dentist, they can do more but its not their fault.
posted by bitdamaged at 8:20 PM on October 21, 2010


The dentist's office generally wouldn't even know where you're up to regarding your annual limits - they vary radically from policy to policy and company to company. It's your insurance company's responsibility to let you know when you've hit one of your coverage limits, and yours to find out in advance the extent to which any given procedure will be covered.
posted by Lolie at 8:27 PM on October 21, 2010


Well hold on a second. I just want to say that in my experience if you're going to the same dentist all year, they -- in my experience -- usually provide this sort of tracking and pre-treatment advising as part of their customer service. Yes, you should stop and ask beforehand. But yes, they should be tracking it, too. (This is moot if you're visiting more than one dentist a year.)
posted by BlahLaLa at 8:28 PM on October 21, 2010 [4 favorites]


Technically the onus is on you, but it's a crappy dentist's office who doesn't lay out beforehand what your procedure will cost, and how much of that is going to be covered. My dentist tracks coverage, schedules around times when the coverage resets, etc. They've always had a number for me and confirmed it before doing any sort of work, even if they didn't expect the payment until much later.
posted by Dr.Enormous at 8:35 PM on October 21, 2010 [3 favorites]


Dr.E's wife here. Our dentist has always been really up front and clear about how much coverage we have left. We're supposed to keep track of it, and we do in that there's not much to usually keep track of, but as soon as we reach near the insurance limit, they pull us aside and tell us what we have left, how much of the procedure will be covered, and if it is really necessary or if it's close enough to the new year's plan to wait to have more covered (if more would even be covered).

And it doesn't help that it can take months to receive an explanation of benefits detailing what's been used, since it's nice they do their own tracking.

I certainly wouldn't feel shy about having a conversation with my dentist about this, just so he'd know that you thought you'd have some warning about the cost.
posted by zizzle at 3:08 AM on October 22, 2010


since = so
posted by zizzle at 3:09 AM on October 22, 2010


most dentists will work out a payment plan of installments with you if you tell them it's a hardship to pay at once.

That's actually becoming more rare that a dentist will take installment payments. At least in my area, dentists are increasingly turning to pushing patients to 3rd-party credit plans/cards like CareCredit and AllCare, if a patient can't pay their bill in one chunk.
posted by Thorzdad at 5:52 AM on October 22, 2010


I don't get how you didn't know that your $1500 was already spent this year.

With your previous infection and couple of fillings, did they go over the paperwork with you before each procedure? If so, how could you not know your total year to date? And if not, then why are you surprised that they didn't do it this time? If they usually do that but didn't this time, why didn't you ask? Does a "broken" tooth indicate more of an "emergency/can't wait" situation and they felt (or they thought that YOU felt) it needed to be fixed immediately?
posted by CathyG at 6:39 AM on October 22, 2010


While people are basically right that it is your responsibility, it is also true that most dentists do keep track of this and let you know, and I'd actually stop visiting a dentist if they did this, assuming they were my regular dentist.
posted by Nothing at 6:52 AM on October 22, 2010


I was once referred to an oral surgeon and their office checked my policy info before giving me an appt that it was going to be $450 out of pocket. Another dentist's office checked me out and then gave me a long list of what they wanted to do and how much it would cost me.

Also, from my work verifying insurance for home IV therapy companies, we always checked for coverage/limit amounts as soon as we got the referral. This wasn't done for the patient's benefit, but rather so that we -- as a business -- had some assurance of getting paid by someone.

So I can't say that it was their *responsibility to you* to check this before doing the procedure -- but within the medical field, it is a common practice that they would check this stuff, for their own benefit, beforehand.
posted by MeiraV at 7:16 AM on October 22, 2010


bitdamaged wrote: "Yes some dentist offices will warn you about this"

When I showed up at a dentist after many years of neglecting my teeth, my dentist, his billing person, and I planned out all the work in advance specifically to work around the yearly coverage limits on my dental plan.

In your case I'd ask for a small discount or to pay half now and half in two weeks or whatever fits you financially. If you want to have them spread it out over longer, they probably will just hand you one of the CareCredit brochures.

Now that I no longer have dental insurance, my dentist is kind enough to knock 10% off. It's just what he does.
posted by wierdo at 7:30 AM on October 22, 2010


Did you get the tooth prepped and had impressions taken to be sent to a lab to have crown made? I'd check my insurance plan and see if they consider crown treatment "done" on impression day or when you come back to have it cemented. If it's cementation date, you can ask your doctor if you can wear your temporary until January. It may need to be remade/recemented, but at a much lower cost than paying entirely out of pocket.

Also, if you do have to pay out of pocket, make sure you are only being billed for what insurance contract price is. For example: If your dentist's fee is $1000 for a crown code, and he is in network for your insurance and has agreed to accept 750 for crowns... he cannot bill you for entire fee even though insurance isn't paying due to over annual max. They still have to treat you as per the contract fees.
posted by Jazz Hands at 10:49 AM on October 22, 2010 [2 favorites]


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